Substance Abuse Evaluation
Please complete the following evaluation. Remember to press submit at the bottom when you are finished.
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First Name *
Last Name *
Address *
City *
State *
ZIP Code *
Age *
Sex *
Race *
Home Phone
Cell Phone
Date of Birth *
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Today's Date *
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Last four of Social Security Number *
Driver's License Number *
Please check the box below to continue with this evaluation: *
Required
Please check the box below to continue with this evaluation: *
Required
Limits of Confidentiality. All communication between counselor and client is held in strictest confidence unless: 1. the client authorizes release of information with a signature, 2. the counselor is ordered by a court to release information, 3. child or elder abuse/neglect are suspected, 4. the client appears to pose a direct threat to his/her or someone else's life (i.e. actively suicidal or homicidal).  We work as a team at Choice Counseling & Evaluation Services, Inc. and the counselor who performed your initial evaluation may be different from your group or individual counselor. Under these circumstances, the counselors will consult with each other in order to provide you with the best possible care. Counselors routinely consult with colleagues regarding cases in order to assess the client's treatment plan and progress. In these situations, the counselor does not disclose client names or other identifying information. Please feel free to ask your evaluator any questions about the above items. *
Required
Court Appearances: The counselors at Choice Counseling & Evaluation Services, Inc. will not appear in court to testify or make any other statements regarding any information concerning client cases. If you are planning any litigation or legal action and would like to have a counselor speak on your behalf, your evaluator will make the necessary referrals in order to provide these services to you. Formal letters for court appearance may be requested, however, at an additional charge. *
Required
Statement of Client Rights: Please read each of the following statements and sign below acknowledging that you have read and understand the conditions. As a client of Choice Counseling & Evaluation Services, Inc., I have the following rights: 1. The right to receive all services available through CC & ES, Inc. for which I am eligible. 2. The right to confidentiality-information about me will not be released without my consent. 3. The right to withdraw from client status with CC & ES, INC. at any time. *
Required
Statement of Client Responsibilities: As a Client of Choice Counseling & Evaluation Services, Inc., I have the following responsibilities: 1. Provide accurate information to the best of my ability. 2. Keep scheduled appointments. I agree to call the office of CC & ES, Inc. in advance of a scheduled appointment if I cannot keep the appointment, to reschedule or cancel. 3. Inform CC & ES, Inc. of change in status (I.E. changes in financial status, health or address; in case of hospitalization, etc.). 4. Respect the confidentiality of others. *
Required
Fee Policy: It is the policy of Choice Counseling & Evaluation Services, Inc. to request our clients pay for services as they are rendered. Should financial difficulties occur; an appropriate payment plan will be arranged. We request clients do not get more than two payments behind. We make every effort to work with our clients' financial status. *
Required
Marital Status *
Education *
What is your current employment status? *
Where do you currently work if you are employed?
What is the name of your position at your current job?
Have you had any of the previous military experience? Check all that apply. *
Required
In your family of origin, how many children (including yourself) did your parents have? *
Thinking about your current living situation, which of the following currently describes where you live? *
Do you rent or own? *
Do you have any children? If so, how many, and what are their ages? *
Do you have a known family history of alcoholism or chemical dependency? Check all that apply. *
paternal
maternal
active
in recovery
none
mother
father
stepmother
stepfather
siblings
grandparents
aunts
uncles
none
Please list all of the following information about the charge that you are doing this evaluation for. If you are not doing an evaluation for a legal charge, please type "N/A" in the box below. 1. The date of the offense. 2. What were the charges? 3. What was the outcome (what was the charge reduced to?) 4. What was the location (City or county)? 5. Were you fined? If so, how much? 6. Were you incarcerated? If so, how long? 7. Did you receive probation? If so, how long? 8. Did you receive any community service? If so, how many hours did you receive? 9. Did you have to complete Risk Reduction School (DUI School)? If so, have you completed it? If you have, please provide your Risk Reduction Certificate Number. 10. Did you have your license revoked? *
Please describe what happened when you were arrested in the box below. (Example: I was speeding and got pulled over and the officer smelled alcohol.) Please be as specific as possible. If your charge includes a Blood Alcohol Content, please list that below as well. If you are not completing this evaluation as part of a legal charge, please type "NA" in the box below. *
Please list any other charges & convictions you have received in the past with the following information on each charge: Month/Year of arrest, what you were convicted of/charged with, and the location (city or county of arrest.) If you have no previous legal history, please type "NA" in the box below. *
Do you have any previous history of major surgeries or medical complications? If yes, please list them and the years. *
Are you currently taking any medications? If yes, please describe the name of the medications & the reason for taking the medications. *
Do you have any known allergies? *
Have you ever been to any alcohol or drug treatment in the past? If so, please tell us the name of the facility, when you attended, and how long you attended. *
Have you ever attended any of the following 12-step groups? *
Required
Have you ever received any counseling in the past? *
At what age did you have your first alcoholic drink? *
When did you have your last alcoholic drink? *
At what age were you when you first used any drugs? *
When was the last time you used any drugs? *
Please check any of the following that apply. Have you ever used any of the following: *
Required
Please describe your pattern of use (i.e. how much and how long you used each of the above listed drugs). *
Do you feel as though you need more of the drug/alcohol to achieve more of the same effect? (tolerance) *
Have you ever experienced any withdrawal symptoms? *
Have you ever used the substance often in larger amounts or over  a longer period of time than you originally intended? (loss of control) *
Has there been a persistent desire or unsuccessful effort to cut back or control your use? *
Have you spent a great deal of time in activities necessary to obtain, use, or recover from the substance? *
Have you ever given up or reduced important social, occupational, or recreational activities because of substance use? *
Have you continued to use the substance despite knowledge of having a persistent or recurrent physical or psychological problem that is caused or made worse by the substance? *
Have you had a past reported history of ALCOHOL/DRUG RELATED: seizures, blackouts, hallucinations, delirium tremens, tremors, ulcers, hepatitis, liver damage, chronic nausea or vomiting, high blood pressure, or pancreatitis? *
Are you currently experiencing facial spider angina or any other signs or symptoms of alcohol withdrawal? *
Has anyone ever mentioned any concerns about your drinking or drug use? *
If so, who mentioned the concerns?
Have you continued the use of alcohol or drugs in the face of any adverse consequences, i.e. legal / marital / employment / medical? *
By typing my full name below, I agree that I have truthfully answered all of the above questions to the best of my knowledge. *
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This form was created inside of Choice Counseling Center.